Superior Mesenteric Artery (SMA) Syndrome. Case of the Month - October 2017 Jane Meng, PGY-2

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1 Superior Mesenteric Artery (SMA) Syndrome Case of the Month - October 2017 Jane Meng, PGY-2

2 Case Study 19F presented to the ER with: Right upper quadrant pain Nausea VomiKng Same day US study was negakve for cholecyskks and cholelithiasis Past medical history of gastric distension NYD requiring NG tube decompression

3 Imaging Findings CECT Superior Mesenteric Artery (SMA) Syndrome Compression of the 3 rd porkon of the duodenum between the superior mesenteric artery (SMA) and abdominal aorta

4 Imaging Findings CECT Distended proximal duodenum Dilated stomach AMD 5 mm with compression of the transverse duodenum Decreased aortomesenteric distance (AMD) between abdominal aorta and SMA (N = mm) on axial plane

5 Imaging Findings Abdominal US AMD 5 mm with compression of the transverse duodenum Decreased aortomesenteric distance (AMD) between abdominal aorta and SMA (N = mm) on transverse plane

6 Imaging Findings CECT Decreased aortomesenteric angle (AMA) on the sagizal plane (N = ) AMA 12 Transverse duodenum

7 Imaging Findings Upper GI Series Barium Upper GI Series Extrinsic compression on transverse duodenum Proximal duodenal dilatakon May see ankperistalkc flow of barium proximal to compressed transverse duodenum

8 SMA Syndrome Clinical PresentaKon Signs & Symptoms Postprandial pain Epigastric pain Weight loss VomiKng Nausea

9 SMA Syndrome Predisposing Factors 1. Weight loss DepleKon of retroperitoneal fat around transverse duodenum Chronic waskng diseases, catabolic states Anorexia, malabsorpkon 2. PostoperaKve states Scoliosis surgery Bariatric surgery 3. Anatomical/congenital anomalies Cephalad dislocakon of duodenum related to high inserkon of ligament of Treitz Low origin of SMA

10 SMA Syndrome - DifferenKal Diagnosis A. Duodenal bowel obstruckon Gastroduodenoscopy can assess for intraluminal obstruckve causes B. Duodenal stricture Ohen posknflammatory secondary to duodenal ulcer C. IntesKnal scleroderma Correlate with non-intesknal findings of scleroderma

11 SMA Syndrome - Treatment 1. Non-operaKve PosiKonal maneuvers to relieve pain: Prone Knee-chest Leh lateral decubitus NG tube decompression of stomach Increase body weight with parenteral or tube feeds 2. OperaKve Duodenojejunostomy Gastrojejunostomy

12 SMA Syndrome - Other ConsideraKons Nutcracker syndrome can occur simultaneously Also due to decreased AMA and AMD Compression of leh renal vein between SMA and abdominal aorta

13 SMA Syndrome - Other ConsideraKons Nutcracker syndrome clinical presentakon Hematuria Leh flank pain Pelvic congeskon Varicocele in males Leh-sided pelvic varicosikes

14 Case Study 19F presented to the ER with: Right upper quadrant pain Nausea VomiKng Same day US study was negakve for cholecyskks and cholelithiasis Past medical history of gastric distension NYD requiring NG tube decompression Treated non-operakvely, symptoms improved

15 References 1. Lamba R, Tanner DT, Sekhon S, McGahan JP, Corwin MT, Lall CG. MulKdetector CT of vascular compression syndromes in the abdomen and pelvis. Radiographics. 2014;34: Unal B, Aktas A, Kemal G, Bilgili Y, Guliter S, Daphan C, Aydinuraz K: Superior mesenteric artery syndrome: CT and ultrasonography findings. Diagn Interv Radiol 2005;11:90 95.

Case Report A Model Example: Coexisting Superior Mesenteric Artery Syndrome and the Nutcracker Phenomenon

Case Reports in Surgery Volume 2015, Article ID 649469, 4 pages http://dx.doi.org/10.1155/2015/649469 Case Report A Model Example: Coexisting Superior Mesenteric Artery Syndrome and the Nutcracker Phenomenon